A postoperative splenectomy patient with recurrent intestinal obstruction presenting with abdominal distention, pain, rigidity, sluggish bowel sounds, stable vital signs, and abdominal X‑ray showing multiple air‑fluid levels: what is the next step in management?

Exploratory Laparotomy is Indicated

This patient requires immediate exploratory laparotomy (Option C) due to the presence of abdominal rigidity, which indicates peritonitis and potential bowel compromise in the setting of recurrent intestinal obstruction. 1

Critical Clinical Reasoning

Why Surgery is Mandatory

The presence of abdominal rigidity is the key finding that distinguishes this case from uncomplicated intestinal obstruction:

• Rigidity indicates peritoneal irritation, suggesting either bowel perforation, ischemia, or strangulation 2, 3
• In a patient with recurrent obstruction post-splenectomy, adhesions are the most likely cause, and the rigidity suggests these adhesions have caused vascular compromise 3, 4
• Sluggish (not absent) bowel sounds combined with rigidity suggests evolving peritonitis rather than simple mechanical obstruction 2

Why Conservative Management (Option D) is Inappropriate

While NGT decompression, bowel rest, and fluid resuscitation are appropriate for uncomplicated intestinal obstruction 3, 4, this patient has signs of peritonitis:

• Conservative management is only indicated when there is no evidence of vascular compromise or perforation 3, 4
• The presence of rigidity represents a surgical emergency that requires immediate exploration to prevent progression to frank perforation and sepsis 2
• Delaying surgery in the presence of peritoneal signs increases morbidity and mortality from bowel necrosis 1, 2

Why Other Options are Incorrect

Paracentesis (Option A) has no role here:

• This is not ascites-related obstruction
• Paracentesis does not diagnose or treat mechanical bowel obstruction 2

Gastrografin enema (Option B) is contraindicated:

• Contrast studies are dangerous in the presence of suspected perforation or peritonitis
• This patient needs surgical exploration, not diagnostic imaging 2, 4

Surgical Approach

Once in the operating room, the exploration should proceed systematically 1:

• Begin at the ileocecal junction and work proximally to identify the point of obstruction 1
• Assess for adhesive bands, the most common cause in post-splenectomy patients (adhesions account for approximately 31.8% of obstructions) 5
• Evaluate bowel viability carefully - if ischemia is present, limited resection and anastomosis should be performed 1
• Lyse adhesions and repair any compromised bowel segments 3, 4

Common Pitfalls to Avoid

• Do not delay surgery when peritoneal signs are present - rigidity mandates immediate exploration 2, 3
• Do not attempt conservative management first in the presence of rigidity, as this represents complicated obstruction 4
• Do not order additional imaging when clinical findings clearly indicate surgical abdomen - this only delays definitive treatment 2